Ricky Crosher and Matthew Osborne
20 May 2026 · Coroner Laurinda Bower · Nottingham City and Nottinghamshire
The coroner's concerns
1. inadequate Safer Custody staffing and resources
“Failure to have in place an appropriately staffed and resourced Safer Custody function”
2. unreliable safer custody telephone line system
“Failure to have in place a robust system for managing the safer custody telephone line”
3. unsafe Care and Separation Unit conditions
“Failure to provide a safe Care and Separation Unit which adhered to expected policy and minimum standards of decency”
4. absence of effective death learning system
“Persistent failure to have in place a robust system for learning from deaths”
5. inadequate evidence retention
“Failure to retain evidence pertinent to the death”
6. poor prison‑healthcare staff collaboration
“Failure to ensure a safe and productive working relationship between prison and healthcare staff”